Background
Cervical cancer was the fourth most common cancer among women worldwide in 2012 [
1]. It was also the eighth most common cancer and the ninth greatest cause of female cancer deaths in Hong Kong in 2014 [
2]. Infection with high-risk type of human papillomavirus (HPV) can lead to cervical cancer and cancers of the vulva, vagina, penis, anus, and oropharynx, and low-risk types can lead to genital warts [
3]. Clinical evidence demonstrates that HPV-associated cancers can be prevented with HPV vaccination [
3]. In Hong Kong, the 4- and 9-valent HPV vaccines are suggested for male and female individuals aged 9 years or older [
4]. However, young women aged 18 years or younger and women who are not yet sexually active are believed to benefit from the vaccine with highest efficacy [
5]. Therefore, school-aged children and young individuals are frequently advised to receive the HPV vaccination [
6]. Children are individuals aged 6–12 years and adolescents are people aged 13–18 years.
In Hong Kong, as at the time of writing, the HPV vaccine is an optional vaccine and not included in the Department of Health’s mandatory Hong Kong Childhood Immunization Programme [
7]. A low HPV vaccination uptake rate occurred in 2008, with only 768 women receiving the HPV vaccine [
8]. This rate did not improve considerably by 2010, and the uptake rate of the HPV vaccination was 7% according to a study among secondary school female students [
9]. The Society of Physicians of Hong Kong and The Family Planning Association of Hong Kong have been providing subsidized HPV vaccines under the Youth HPV Prevention Programme to primary and secondary school students since 2011 at a discounted rate of HK$2000 (~US$256) for the whole course [
10]. Only in 2016 did the role of the Hong Kong Government in HPV vaccination intensify, with the Community Care Fund under the Hong Kong Government launching an initiative known as the Free Cervical Cancer Vaccination Pilot Scheme, which offers free HPV vaccination to girls aged 9–18 years from low-income families receiving Comprehensive Social Service Assistance [
11].
HPV may infect 75% of sexually active people [
12]. Although receiving HPV vaccination is an effective method of preventing infection, receiving vaccination is not necessarily a straightforward decision for people to make [
13,
14], and many social and cultural factors interact to influence people’s approval of the vaccine.
The health perceptions and behavior of children and teenagers are notably influenced by significant others [
15]. Schoolteachers in particular serve as a key medium and role model for imparting knowledge and socializing children and teenagers regarding health knowledge. Schools are the most popular venues for implementing health education and vaccination programs to students in Hong Kong. The home-school-doctor model initiated by The Chinese University of Hong Kong, for instance, features collaboration among schoolteachers, parents, and doctors in enhancing the health of students. This model has employed support from schools and improved the vaccine uptake rate of adolescents to over 30% [
16]. The availability of this model was reported to be the most significant independent factor for adolescents’ uptake of the vaccine (OR 26.6; 95% CI 16.4, 41.9) [
16]. Therefore, the perspective of schools and schoolteachers can significantly influence the acceptability and accessibility of the vaccine by students and their parents, and thus influence the vaccination rate. Studies have reported on the low acceptability of the HPV vaccine by mothers and female university students in Hong Kong [
17,
18]. Although schoolteachers have been observed to play an extraordinary role in modeling student health perceptions and behavior [
19], few studies have been conducted toward understanding the attitudes of schoolteachers themselves toward the HPV vaccination, and even fewer concerning how schoolteachers’ perceptions influence their schools’ motivation and decisions to implement school-based HPV vaccination programs. The few studies that have discussed this subject have been conducted in non-Asian countries [
20‐
22] and with a paucity of Chinese-based research.
Many adolescents are oblivious to the importance of receiving HPV vaccination as a preventive health measure [
23], partly because of a lack of support and education from schools. Therefore, increasing the awareness of schools and schoolteachers is crucial to motivating adolescents to receive vaccination, thus reducing the prevalence and disease burden of cervical cancer and HPV-associated diseases in Hong Kong. This study investigated how schoolteachers in primary and secondary school students in Hong Kong perceive HPV and HPV vaccines, their experiences regarding implementation of HPV vaccination programs in schools, their thoughts regarding students’ need for receiving the vaccination, and the incentives and barriers for them to implement HPV vaccination programs in their schools.
Discussion
Schoolteachers’ perceptions of and beliefs about the HPV vaccine can have a decisive role in influencing students’ accessibility to and acceptance of the vaccine. School-based interventions can positively influence beliefs regarding the prevention of HPV and increase HPV vaccination rates in adolescents [
30]. However, as the findings indicate, organizing a school-based HPV vaccination program is never straightforward. Perceptual, cultural, institutional, parental, and collaborator barriers interact to discourage the sampled schoolteachers from organizing vaccination programs.
HPV vaccine perceptions among the sampled schoolteachers played a crucial role in motivating or discouraging them from organizing school-based HPV vaccination programs. The participants commonly lacked knowledge regarding the HPV vaccine, particularly those from nonorganizing schools. They felt unclear regarding use of the vaccine, vaccine efficacy, and the target population. This uncertainty led to their hesitation in organizing school-based vaccination programs. However, participants who had organized HPV vaccination programs in their schools had more knowledge of HPV and the HPV vaccine, and a close relationship between personal vaccination status of participants and a tendency to organize school-based HPV vaccination programs was observed. The five participants who had received the HPV vaccine had organized HPV vaccination programs in their schools. This demonstrated a positive relationship between knowledge of HPV and the HPV vaccine and motivation to organize school-based HPV vaccination programs, which coincided with findings from South Africa [
31]. Therefore, providing more public health education regarding HPV and the HPV vaccination to schoolteachers may empower them to implement school-based vaccination programs and related health education for students.
Not believing their students needed to receive the HPV vaccine, the participants were not inspired to organize school-based HPV vaccination programs. They perceived the concept of cervical cancer as too difficult for their students to comprehend because they had not yet reached an age in which they were generally considered vulnerable. Furthermore, the term used to refer to the HPV vaccine—“cervical cancer vaccine”—throughout the interviews explained this attitude. According to the Sapir–Whorf Hypothesis, language affects a person’s thinking. The language and vocabulary used can influence speakers’ perceptions and thus affect their attitudes, behavior, and worldview [
32]. Referring to the HPV vaccine as the cervical cancer vaccine reflected the participants’ perceptions that the vaccine is merely for preventing cervical cancer, a disease that was perceived as irrelevant to their students. Although such attitudes were also present among those who had organized school-based HPV vaccination programs, these participants had a more positive view, regarding the vaccination program as a form of health education and brought to their students the message of disease prevention.
Although irrelevance to student needs was a notable barrier preventing school-based HPV vaccination programs, this did not necessarily indicate that the participants would only organize health education activities they thought were relevant to their students’ needs. Health education activities regarding colorectal cancer prevention, for instance, were common in the participants’ schools, even though colorectal cancer rarely affects adolescents according to the medical literature [
33]. We argued that a key reason for this difference in the attitude is the traditional cultural values and stereotypes regarding cervical cancer, HPV, and the HPV vaccine in Chinese communities. These and other factors interacted to explain the participants’ and their schools’ reluctance to organize school-based HPV vaccination programs.
Concerns of students’ sexual attitudes were an obstacle. Cervical cancer is caused by sexual activity [
34], thus organizing school-based HPV vaccination programs is perceived as demonstrating schools’ approval for premarital sexual behavior, which violates the traditional Chinese cultural value of chastity before marriage. This impedes young adults’ HPV vaccination uptake [
17,
18]. Because schools are critical social institutions of socialization, contributing to how students behave in accordance with society’s expected social and cultural norms and values, schools are thus not expected to organize programs that break with these values, including the participants and other stakeholders, such as the school management and parents. Moreover, organizing school-based HPV vaccination programs was even less straightforward for schools with certain religious backgrounds, in which the support of the school management was entirely lacking. An effective health promotion program must address participants’ perception of social norms [
35] and enriching health education in this area would cultivate a positive normative belief in the desired practice by inducing the motivation to comply (i.e., vaccine uptake).
All these issues result in HPV vaccination often having the lowest priority in schools’ health education curricula. To the participants and school management, the immediate impact of cervical cancer on students is negligible because of their belief in their students’ abstinence and the moral and cultural implications of the HPV vaccination that prevented the participants from organizing such health-enhancing, but morally and culturally sensitive, programs. Therefore, other health education and vaccination activities that warranted immediate attention and that lacked moral and cultural implications, such as the seasonal influenza vaccination and colorectal cancer education, were much higher on the agenda. The participants preferred to employ the fear appeal of cervical cancer to regulate students’ sexual attitudes and behaviors.
As a powerful social institution, the government health and education authorities played a prevalent role in downplaying the importance of HPV vaccination. The government health authorities did not openly promote the importance of HPV vaccination to the public before the government’s Policy Address of 2018. This in turn influenced the participants’ perceived need of providing vaccination to their students. Under this policy influence, it was extremely difficult for schoolteachers to obtain information, education, and support regarding the HPV vaccine from the authorities, making the HPV vaccine appear unimportant. Therefore, government health authorities and their vaccination policies serve a remarkable role in affecting participants’ perceived (un) importance in vaccinating students. The perceived unimportance of vaccinating students against HPV, however, may change in future, as the government will introduce free HPV vaccination to school girls of particular age-groups starting from the 2019/2020 school year [
36]; hopefully this will alter the perceptions of HPV vaccine in the community.
Unlike in the United States, where mothers are willing to vaccinate their daughters against HPV in a school-based format [
37], this study’s participants noted a contrasting opinion from parents. Parents’ attitudes affected the participants’ motivation. Parents are the predominant partners of schools and schoolteachers according to the home-school-doctor model [
16]. Without the support of parents, the participants could not justify the organization of school-based HPV vaccination programs.
The nature of collaborating organizations also played a key role in motivating participants to organize school-based HPV vaccination programs. The credibility of health care is diminished when associated with commercial companies because of the stereotype of commerce as profit-making, leading to people’s suspicion and lack of confidence in health care measures [
38]. Nongovernmental health organizations and universities were observed to be the most trustable and credible institutions according to the participants’ perceptions. Moreover, the involvement of nongovernmental organizations in school-based vaccination programs achieved an 80% acceptance rate among students and parents [
39], supporting the adoption of the home-school-doctor model as a meaningful approach to school-based HPV vaccination programs [
16]. Therefore, collaborating with nongovernmental health organizations and universities could be a feasible direction for school-based HPV vaccination programs in the future. Furthermore, school-based health centers in the United States were reported to improve HPV vaccine uptake among adolescents because they offer convenience and do not affect school or work [
40]. Despite the lack of school-based health centers in primary and secondary schools in Hong Kong, with the support of the literature indicating school-based format can enhance vaccination motivation [
37,
40‐
43] and offer trust to parents [
44], the home-school-doctor model could be considered an alternative in the implementation of school-based HPV vaccination programs [
16] in the future to improve vaccine uptake.
Consistent with literature [
45], the high cost of the vaccine affected the perceived importance of receiving vaccination. Although providing monetary subsidies could have helped increase vaccination incentives, many other social and cultural factors interacted to affect the participants’ perceptions and thus their motivations in organizing school-based HPV vaccination programs. Further public health education regarding HPV and information on the HPV vaccine must be provided to sway these crucial stakeholders. As students only have limited autonomy in making vaccination decisions and are still undergoing socialization from their significant others, such as schoolteachers, providing public health education regarding HPV and the HPV vaccine to schoolteachers is crucial to enhancing their awareness on the importance of receiving vaccination, which can in turn encourage students to adopt this preventive health behavior.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.